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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006070
Report Date: 03/13/2023
Date Signed: 03/13/2023 02:59:33 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230309101851
FACILITY NAME:COASTAL CHARM OF TUSTINFACILITY NUMBER:
306006070
ADMINISTRATOR:ALI, AHMADFACILITY TYPE:
740
ADDRESS:13341 ETON PLACETELEPHONE:
(949) 357-7633
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 2DATE:
03/13/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ahmad Ali, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not release resident's records to resident's responsible party
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of investigating the allegation listed above. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit and detailing the allegation. Administrator Ahmad Ali was notified of the visit by telephone and arrived shortly afterwards to assist with the visit.

LPA accompanied by caregiver conducted a tour of the physical plant. LPA requested obtained and reviewed resident records for resident R1 including, but not limited to, the following documents:
- Signed copy of admission agreement dated January 25, 2023
- Signed copy of resident's personal rights

An interview of administrator Ahmad Ali was conducted during the visit.

CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20230309101851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COASTAL CHARM OF TUSTIN
FACILITY NUMBER: 306006070
VISIT DATE: 03/13/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility did not release resident's records to resident's responsible party, the following has been concluded:
On March 6, 2023, licensee received a formal request to make available the records of resident R1 to the resident's responsible party and legal representative. Administrator stated records were requested as part of a possible ongoing litigation with a Skilled Nursing Facility the resident was admitted to prior to his stay at Coastal Charm of Tustin - 306006070. Records were stated to have been made available on March 13, 2023 prior to the present facility visit being conducted by resident R1 legal representative and by administrator.

As a result, the above allegation is deemed to be Unfounded, meaning that the allegation is false, could not have happened or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC9099 (FAS) - (06/04)
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